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Safety Recommendation Details

Safety Recommendation A-12-060
Details
Synopsis: On April 2, 2011, about 0934 mountain daylight time, an experimental Gulfstream Aerospace Corporation GVI (G650), N652GD, crashed during takeoff from runway 21 at Roswell International Air Center, Roswell, New Mexico. The two pilots and the two flight test engineers were fatally injured, and the airplane was substantially damaged by impact forces and a postcrash fire. The airplane was registered to and operated by Gulfstream as part of its G650 flight test program. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident.
Recommendation: TO THE FLIGHT TEST SAFETY COMMITTEE: In collaboration with the Federal Aviation Administration, develop and issue flight test safety program guidelines based on best practices in aviation safety management, and encourage manufacturers to incorporate these guidelines into their flight test safety programs.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: Roswell, NM, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA11MA076
Accident Reports: Crash During Experimental Test Flight, Gulfstream Aerospace Corporation GVI (G650), N652GD
Report #: AAR-12-02
Accident Date: 4/2/2011
Issue Date: 10/23/2012
Date Closed: 7/20/2016
Addressee(s) and Addressee Status: Flight Test Safety Committee (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Flight Test Safety Committee
Date: 7/20/2016
Response: We note that you have posted “Flight Test SMS Protocols” in the Best Practices section of the FTSC website, and that on May 5, 2016, Mr. Huff presented these protocols to the Flight Test Safety Workshop held in Melbourne Florida. These actions satisfy Safety Recommendation A 12 60, which is classified CLOSED—ACCEPTABLE ACTION.

From: Flight Test Safety Committee
To: NTSB
Date: 4/15/2016
Response: -From Gerald W. Whites, Chairman, Flight Test Safety Committee: The FTSC produced SMS auditing protocols from two of the most prototypical sources; the International Business Aircraft Council (IBAC -specifically, the International Standard for Business Aircraft Operations ISBAO) and the Safety Management International Collaborative Group (SMICG). Appropriate elements of FAA AC 120-92 (Safety Management Systems for Aviation Service Providers), FAA Order 4040.26 (Aircraft Certification Service Flight Test Risk Management Program), and FAA Order 8000.369 (Safety Management System Guidance) were also incorporated to produce not only a comprehensive auditing tool, but also a template for test organizations to develop and mature their respective safety processes. The safety management guidelines that are contained in the preamble material of each of the Safety Management System "pillars" of Policy, Risk Management, Assurance, and Promotion, detail the best practice philosophy and safety performance expectation specific to flight test organizations. The FTSC hosted these auditing protocols on the flighttestsafety.org web site and to date, one aircraft manufacturer and a (FTSC) participating FAA Aircraft Certification Office have exercised the protocols with positive feedback from highly experienced SMS auditors. The FTSC intends to present the results of this recommendation to the Flight Test Safety Workshop held in Melbourne Florida on May 5, 2016 to promote widespread use of these protocols among the flight test community. The FTSC considers this recommendation OPEN pending completion of the Flight Test Workshop presentation and incorporation of any feedback from participating manufacturers.

From: NTSB
To: Flight Test Safety Committee
Date: 6/18/2015
Response: We note that you are currently adapting the safety management system (SMS) auditing protocols from the International Business Aircraft Council’s International Standard for Business Aircraft Operations (IS-BAO) and the Safety Management International Collaborative Group. In addition, you are also incorporating key elements of FAA advisory circular 120-92, “Safety Management Systems for Aviation Service Providers,” FAA Order 4040.26, ”Aircraft Certification Service Flight Test Risk Management Program,” and FAA Order 8000.369, “Safety Management System Guidance.” We further note that, after you have completed this work, you plan to perform some sample audits to evaluate the system, after which you intend to distribute the protocols through the FTSD and to meetings of the Society of Experimental Test Pilots and the Society of Flight Test Engineers. Pending completion of the SMS audit protocols, their testing, and their release to the flight test community, Safety Recommendation A-12-60 is classified OPEN—ACCEPTABLE RESPONSE.

From: Flight Test Safety Committee
To: NTSB
Date: 11/25/2014
Response: -From Gerald Whites, Chairman, Flight Test Safety Committee: The Flight Test Safety Committee hosts two annual workshops – one in the U.S. and the other in Europe. These international events provide an effective exchange of flight test safety related information and safety guidance deliverables. Relevant briefing topics are then identified for presentation at the full-membership symposia of the Society of Experimental Test Pilots (SETP) and the Society of Flight Test Engineers (SFTE). Member chapter organizations typically request similar material for those unable to attend the other conferences. Implementation of the Safety Management System (SMS) construct is a recognized best practice in flight departments but relatively new to the flight test community. Notwithstanding, many of the components already exist within flight test departments and simply need to be integrated into the SMS framework. The FTSC is underway at adapting the SMS auditing protocols from the International Business Aircraft Council (IBAC – specifically, the International Standard for Business Aircraft Operations IS-BAO) and the Safety Management International Collaborative Group (SMICG). Key elements of FAA AC 120-92 (Safety Management Systems for Aviation Service Providers), FAA Order 4040.26 (Aircraft Certification Service Flight Test Risk Management Program), and FAA Order 8000.369 (Safety Management System Guidance) will also be incorporated. The Committee considers this action to remain OPEN until beta testing has been completed on sample audit protocols at which time they will be offered to the test community writ-large via FTSD, SETP and SFTE web sites (estimated completion: Sep 2015). In summary, the FTSC is an all-volunteer committee that is part of the Society of Experimental Test Pilots (SETP) Foundation (501c(3) not-for-profit) chartered to enhance flight test safety through professional enrichment and industry-wide collaboration. The Committee is comprised of industry experts, manufacturer flight test safety representatives, and FAA/EASA flight test experienced personnel. Components of the NTSB recommendations are already being exercised, and with improvements to the FTSD resource center, the tools will be easily accessed and scalable to all flight test activities. The Committee is encouraged by increasing participation and collaboration among OEMs to share and embrace best practices that will ensure flight test risks are continually mitigated to the maximum extent practicable.

From: NTSB
To: Flight Test Safety Committee
Date: 10/3/2014
Response: In January 2014, NTSB staff spoke informally to some members of the FTSC regarding actions that you had planned to take in response to these recommendations. We are interested in knowing whether and how our recommendations are implemented, both to ensure that the traveling public is provided the highest level of safety and to identify creative solutions that might be shared with others. Our recipients usually complete actions to implement our safety recommendations within 3 to 5 years of issuance. As these recommendations were issued almost 2 years ago, and to date we have received no formal reply from you regarding actions that you have either taken or planned in response to them, we would appreciate receiving a response within 90 days indicating such actions. Pending your timely reply, Safety Recommendations A 12 59 through 61 will retain their current classification of OPEN—AWAIT RESPONSE.